1. VTE prophylaxis in hospitalized oncology patient
ASCO- acutely ill patients recommend LMWH. It does not recommend thromboprophylaxis in patients admitted for chemotherapy or stem cell transplantation.
Prophylaxis may be offered to hospitalized medical oncology patients without risk factors
NCCN 2020- MLWH, UFH or fondaparinux if no contraindication
ISTH 2014- Recommend pharmacologic thromboprophylaxis for patients with platelets ≥50,000/μL.
Suggest individualized approach to patients with platelets 25,000–49,000/μL.
Recommend against pharmacologic thromboprophylaxis in patients with platelets <25,000/μL
| International Initiative on Thrombosis in Cancer 2019 | Recommend LMWH or fondaparinux (when CrCl is ≥30 mL/min) or UFH recommended in hospitalized patients with cancer and reduced mobility (grade 1B). DOACs not recommended routinely in this setting (guidance). |
2. Ambulatory oncology patients
ASCO- routine thromboprophylaxis for all patients not indicated. High risk or intermediate risk cancer patients with Khorana score 2 or higher may benefit. LMWH or DOAC.
Patients with multiple myeloma receiving thalidomide‐ or lenalidomide‐based regimens with chemotherapy and/or dexamethasone should be offered thromboprophylaxis with either aspirin or LMWH (lower‐risk patients) or LMWH (higher‐risk patients). (Recommendation type: evidence‐based; evidence quality: intermediate; strength of recommendation: strong.)
NCCN 2020- Consider apixaban or rivaroxaban for up to 6 months in high‐risk patients with cancer (KRS ≥2) starting a new chemotherapy regimen (grade 2A).
Recommend LMWH or VKA (INR 2–3) for high‐risk patients with myeloma (IMPEDE‐VTE score >3 points or SAVED score ≥2 points) (grade 2A).
Recommend aspirin (81–325 mg daily) or no prophylaxis for low‐risk patients with myeloma (IMPEDE‐VTE score ≤3 points or SAVED <2 points) (grade 2A).
3. Cancer patients- perioperative prophylaxis
ASCO 2020- All patients undergoing major surgery should be offered pharmacological prophylaxis with UFH or LMWH unless contraindicated. (Recommendation type: evidence‐based; evidence quality: high; strength of recommendation: strong.)
Prophylaxis should be commenced preoperatively,ct up to 4 weeks in high risk abdominal or pelvic surgery.
What is high risk: obesity, immobility, prior VTE.
ITAC: high risk--anesthesia time >2 hours, gastrointestinal (GI) malignancies, previous VTE, advanced‐stage disease, bed rest of ≥4 days, or age >60 years in addition to ASCO high risk
| International Initiative on Thrombosis and Cancer 2019 | LMWH (if CrCl ≥30 mL/min) once daily or low‐dose UFH three times a day is recommended. Pharmacologic prophylaxis should be started 2–12 hours preoperatively and continued for at least 7–10 days. No data to suggest one LMWH superior to another (grade 1A). Values and preferences: Once‐daily LMWH more convenient. |
4. Cancer associated thrombosis
ASCO: For patients with primary or metastatic CNS malignancies and VTE, anticoagulation should be offered, although uncertainty remains as to choice of agent and the type of patients most likely to benefit.
No role for IVC filter except absolute CI to anticoagulation; progressive thrombosis despite maximal anticoagulation
Rx LMWH, DOAC, fondaparinux.
Duration of rx for CAT--> ASCO 6 months or beyond for those with metastatic disease. NCCN recommends 3 months at least or for as long as cancer is active or undergoing treatment, whichever is longer
DOACs are associated with increased major bleeding in GI and potentially GU malignancies. Caution with DOACs is warranted in other settings with high risk for mucosal bleeding. Drug‐drug interactions should be checked before use of DOACs
ISTH-Suggest edoxaban and rivaroxaban for patients with cancer with acute VTE, a low risk of bleeding, and no drug‐drug interactions. LMWHs are an acceptable alternative. Suggest LMWH for patients with acute VTE at high risk for bleeding, including those with luminal GI malignancy with intact primaries, GU malignancies, nephrostomy tubes, or GI mucosal abnormalities. Edoxaban and rivaroxaban are acceptable alternatives if no drug‐drug interactions.
IVC filters may be considered for initial treatment when anticoagulation is contraindicated or when PE occurs despite optimal anticoagulation.
In the event of recurrent VTE, three options can be considered: (a) increase LMWH by 20%–25% or switch to DOAC; (b) for DOACs, switch to LMWH; and (c) for VKAs, switch to LMWH or DOAC.
NCCN 2020- Apixaban (category 1), edoxaban after at least 5 days of parenteral anticoagulation (category 1), or rivaroxaban (category 2A) preferred over LMWH for patients without GI malignancies.
Dabigatran after at least 5 days of parenteral anticoagulation (alternative to apixaban, edoxaban, rivaroxaban, or LMWH if not appropriate or unavailable) (category 2A).
LMWH (dalteparin category 1) preferred over DOACs in patients with GI malignancies.
Apixaban and edoxaban are contraindicated in patients with clinically significant liver disease (total bilirubin >1.5 × ULN or transaminases >2 × ULN). Dabigatran and rivaroxaban are contraindicated if transaminases >3 × ULN.
Dabigatran, edoxaban and rivaroxaban are contraindicated with CrCl <30 mL/min. Apixaban is contraindicated if CrCl <25 mL/min.
Apixaban and rivaroxaban should not be used in conjunction with strong inducers/inhibitors of CYP3A4 and P‐glycoprotein.
Dabigatran and edoxaban should not be used in conjunction with strong inducers/inhibitors of P‐glycoprotein.
Recurrent VTE -treatment
For recurrent VTE on UFH, recommend considering HIT, antiphospholipid syndrome (check UFH anti‐Xa level), increase dose of UFH, or switch to LMWH or DOAC (category 2B).
For recurrent VTE on LMWH, recommend considering HIT, switch to twice‐daily injections or increase dose or switch to fondaparinux or DOAC (category 2B).
For recurrent VTE on fondaparinux, recommend considering HIT or switching to UFH, LMWH, or DOAC (category 2B).
For recurrent VTE on warfarin, recommend switching to LMWH, UFH, fondaparinux, or DOAC (category 2B).
For recurrent VTE on DOAC, recommend switching to LMWH or fondaparinux (category 2B).
https://theoncologist.onlinelibrary.wiley.com/doi/epdf/10.1002/onco.13596
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